Today HHS Secretary Sylvia Burwell announced that, through the Affordable Care Act (ACA), Medicare would be taking drastic steps to assure that doctors are paid not for visits and procedures, but rather for the value of their work. The CMS website states that “providers must make fundamental changes in their day-to-day operations that improve the quality and reduce the cost of health care.”
I am a full-time practicing primary care physician. Although I have studied the health care system and recently written a book about Medicare (Curing Medicare), I am not an academic or policy maker, but rather a doctor who sees elderly patients five days a week, and have done so for a quarter century. I participate in the many innovations that CMS has proclaimed will enable us to achieve superior care at lower cost: Electronic medical records (EMR), Quality measures (PQRS) and Accountable Care Organizations (ACO’s). I supported the ACA and valued its emphasis on primary care. But like many practicing doctors, I feel as though what I am reading in the press about the ACA’s innovations, and what I am living day to day in my office, are polar opposites.
In perusing stories about the Secretary’s announcement I was struck that no practicing doctors were interviewed. Thought leaders, academics, organizational presidents, but no actual practicing doctors. And yet when I turned to one source, Medscape Internal Medicine, by early evening scores of practicing doctors had already chimed in, every one of whom knew that the ACA’s proclamation was injurious to doctor and patient alike. Currently over 80% of primary care doctors feel powerless in the wake of government mandates. Only 20% of medical students are entering primary care. What are we all seeing that the pundits and politicians are not?
The truth is that we cannot measure quality. Medicare’s quality indicators often verge sharply from true quality geriatric care, and yet it is our compliance with those numbers that will now determine our salary. Rather than having time to talk to my patients, I often find myself madly typing notes into a computer to comply with Medicare’s regulations, ordering tests and using drugs to comply with Medicare’s quality indicators, and filling out reams of paperwork to comply with Medicare’s new regulations. Under Medicare’s payment rules it is far easier for me to send elderly patients to the hospital, where they often receive inferior care, than to try to treat them at home, which is where they would prefer to be. To Medicare and ACA reformers, quality and value are broken down into discrete measurements that must be entered into a computer exactly as Medicare dictates. Failure to do so could lead to crippling fines. I have been audited twice already in the past year, with more audits to come. No wonder patients must face doctors who stare at computer screens and do not have time to listen. That is the result of the ACA’s quest for value. In fact, CMS’s announcement today stipulated that its two goals were to increase accountability for quality/cost of care, and to put a greater focus on population health management. To the patient sitting in front of me, population health management and generic quality indicators are not helping them to achieve better health or higher quality. In fact, patients are mere cogs in the new systems that the ACO is devising.
There is a better way forward, something I discuss at length in my book, and which so many of us in primary care know through our experience. Eliminate the templates and scripted notes we have to complete, erase the erroneous measures of quality to which we are told to adhere, reduce the paperwork burdens needed to obtain basic health care, and allow us to meaningfully care for our patients. Remove the money from hospitals, which is where most ACA/CMS funding flows, and allow us in primary care to steer the ship. Enable us to treat patients as they want to be treated, to discuss with them the pros and cons of tests and treatments, and to personalize care. Provide patients with choice: they can go to the hospital, or get care at home for the same price; they can get an MRI for their back pain, or have acupuncture treatment. It does not take a room full of experts and a book of rules, regulations, and acronyms to fix our health care system. It takes common sense. Talk to practicing primary care doctors. You may learn something of real value.